Download Chapter 21. Pain Medical Treatment Guidelines Subchapter B

Chapter 21. Pain Medical Treatment Guidelines
Subchapter B. Complex Regional Pain Syndrome
Editor’s Note: Form LWC-WC 1009. Disputed Claim for Medical Treatment has been moved to §2328 of this Part.
§2117. Introduction
A. This document has been prepared by the Louisiana Workforce Commission, Office of Workers’
Compensation and should be interpreted within the context of guidelines for physicians/providers treating
individuals qualifying under Louisiana’s Workers’ Compensation Act as injured workers with cervical spine injuries.
These guidelines are enforceable under the Louisiana Workers Compensation Act. All medical care, services, and
treatment owed by the employer to the employee in accordance with the Louisiana Workers’ Compensation Act shall
mean care, services, and treatment in accordance with these guidelines. Medical Care, services, and treatment hat
varies from these guidelines shall also be due by the employer when it is demonstrated to the medical director of the
office by a preponderance of the scientific medical evidence, that a variance from these guidelines is reasonably
required to cure or relieve the injured worker from the effects of the injury or occupational disease given the
circumstances. Therefore, these guidelines are not relevant as evidence of a provider’s legal standard of professional
care. To properly utilize this document, the reader should not skip nor overlook any sections.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1716 (June 2011).
§2119. General Guideline Principles
A. The principles summarized in this section are key to the intended implementation of all Office of Workers’
Compensation guidelines and critical to the reader’s application of the guidelines in this document.
1. Application of Guidelines. The OWCA provides procedures to implement medical treatment guidelines and
to foster communication to resolve disputes among the provider, payer, and patient through the Office of Worker’s
Compensation.
2. Education. Education of the patient and family, as well as the employer, insurer, policy makers and the
community should be the primary emphasis in the treatment of workers’ compensation injuries. Currently,
practitioners often think of education last, after medications, manual therapy, and surgery. Practitioners must develop
and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers, and
the community as a whole. An education-based paradigm should always start with inexpensive communication
providing reassuring information to the patient. More in-depth education currently exists within a treatment regime
employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is
complete without addressing issues of individual and/or group patient education as a means of facilitating selfmanagement of symptoms and prevention.
3. Treatment parameter duration Time frames for specific interventions commence once treatments have been
initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as
availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames
discussed in this document. Such deviation shall be in accordance with La. R.S. 23:1203.1.
4. Active interventions emphasizing patient responsibility, such as therapeutic exercise and/or functional
treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive
interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant
attainment of objective functional gains.
5. Active Therapeutic Exercise Program. Exercise program goals should incorporate patient strength,
endurance, flexibility, coordination, and education. This includes functional application in vocational or community
settings.
6. Positive Patient Response. Positive results are defined primarily as functional gains that can be objectively
measured. Standard measurement tools, including outcome measures, should be used.
a. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion (ROM),
strength, and endurance, activities of daily living, cognition, psychological behavior, and efficiency/velocity
measures that can be quantified. Subjective reports of pain and function should be considered and given relative
weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective
findings.
7. Re-Evaluation of Treatment Every Three to Four Weeks. If a given treatment or modality is not producing
positive results within three to four weeks, the treatment should be either modified or discontinued. Reconsideration
of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
8. Surgical Interventions. Surgery should be contemplated within the context of expected improvement of
functional outcome and not purely for the purpose of pain relief. The concept of "cure” with respect to surgical
treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of
clinical findings, clinical course, and diagnostic tests. A comprehensive assimilation of these factors must lead to a
specific diagnosis with positive identification of pathologic conditions. The decision and recommendation for
operative treatment, and the appropriate informed consent should be made by the operating surgeon. Prior to surgical
intervention, the patient and treating physician should identify functional operative goals and the likelihood of
achieving improved ability to perform activities of daily living or work activities and the patient should agree to
comply with the pre- and post-operative treatment plan and home exercise requirements. The patient should
understand the length of partial and full disability expected post-operatively.
9. Pharmacy-Louisiana Law and Regulation. All prescribing will be done in accordance with the laws of the
state of Louisiana as they pertain respectively to each individual licensee, including, but not limited to: Louisiana
State Board of Medical Examiners regulations governing medications used in the treatment of non-cancer-related
chronic or intractable pain; Louisiana Board of Pharmacy Prescription Monitoring Program; Louisiana Department
of Health and Hospitals licensing and certification standards for pain management clinics; other laws and regulations
affecting the prescribing and dispensing of medications in the state of Louisiana.
10. Six Month-Time Frame. The prognosis drops precipitously for returning an injured worker to work once
he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to
move patients along a continuum of care and return-to-work within a six-month time frame, whenever possible. It is
important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not
occupationally related.
11. Return To Work. Return to work is therapeutic, assuming the work is not likely to aggravate the basic
problem or increase long-term pain. The practitioner must provide specific written physical limitations. If a
practitioner releases a patient at a level of function lower than their previous job position, the practitioner must
provide physical limitations and abilities and job modifications. A patient should never be released to simply
“sedentary” or “light duty.” The following physical limitations should be considered and modified as recommended:
lifting, pushing, pulling, crouching, walking, using stairs, climbing ladders, bending at the waist, awkward and/or
sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive
motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is
not necessarily contraindicated. The practitioner should understand all of the physical demands of the patient’s job
position before returning the patient to full duty and should request clarification of the patient’s job duties.
Clarification should be obtained from the employer or, if necessary, including, but not limited to, an occupational
medicine physician, occupational health nurse, physical therapist, occupational therapist, vocational rehabilitation
specialist, or an industrial hygienist.
12. Delayed Recovery. Strongly consider a psychological evaluation, if not previously provided, as well as
initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to
make expected progress 6 to 12 weeks after an injury. The OWCA recognizes that 3 to 10 percent of all industrially
injured patients will not recover within the timelines outlined in this document despite optimal care. Such
individuals may require treatments beyond the limits discussed within this document, but such treatment will require
clear documentation by the authorized treating practitioner focusing on objective functional gains afforded by
further treatment and impact upon prognosis.
13. Guideline Recommendations and Inclusion of Medical Evidence. Guidelines are recommendations based on
available evidence and/or consensus recommendations. When possible, guideline recommendations will note the
level of evidence supporting the treatment recommendation. When interpreting medical evidence statements in the
guideline, the following apply to the strength of recommendation.
Strong
Moderate
Level 1 Evidence
Level 2 and Level 3 Evidence
We Recommend
We Suggest
Weak
Inconclusive
Level 4 Evidence
Treatment is an Option
Evidence is Either Insufficient of Conflicting
a. Consensus guidelines are generated by a professional organization that the guidelines are intended to
serve. A committee of specialists and experts are selected by the organization to create an unbiased, vetted
recommendation for the treatment of specific issues within the realm of their expertise. All recommendations in the
guideline are considered to represent reasonable care in appropriately selected cases, regardless of the level of
evidence or consensus statement attached to it. Those procedures considered inappropriate, unreasonable, or
unnecessary are designated in the guideline as “not recommended.”
B. The remainder of this document should be interpreted within the parameters of these guideline principles that
may lead to more optimal medical and functional outcomes for injured workers.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1716 (June 2011), amended by the Louisiana Workforce Commission, Office of Workers Compensation,
LR 40:1157 (June 2014).
§2121. Introduction to Complex Regional Pain Syndrome
A. Complex regional pain syndrome (CRPS types I and II) describes painful syndromes, which were formerly
referred to as reflex sympathetic dystrophy (RSD) and causalgia. CRPS conditions usually follow injury that appears
regionally and have a distal predominance of abnormal findings, exceeding the expected clinical course of the
inciting event in both magnitude and duration and often resulting in significant impairment of limb function.
B. CRPS-I (RSD) is a syndrome that usually develops after an initiating noxious event, is not limited to the
distribution of a single peripheral nerve, and is apparently disproportionate to the inciting event. It is associated at
some point with evidence of edema, changes in skin, blood flow, abnormal sudomotor activity in the region of the
pain, allodynia or hyperalgesia. The site is usually in the distal aspect of an affected extremity or with a distal to
proximal gradient. The peripheral nervous system and possibly the central nervous system are involved.
C. CRPS-II (causalgia) is the presence of burning pain, allodynia, and hyperpathia usually in the hand or foot
after partial injury to a nerve or one of its major branches. Pain is within the distribution of the damaged nerve but
not generally confined to a single nerve.
D. Stages seen in CRPS-I are not absolute and in fact, may not all be observed in any single patient. In some
patients, stages may be missed or the patient may remain for long periods of time in one stage.
E. Stage 1Acute (Hyperemic)
1. Starts at the time of injury or even weeks later. Associated with spontaneous pain, aching, burning.
Typically restricted to the distal extremity. Hyperpathia, allodynia, hypoesthesia or hyperesthesia may be present.
Initially, hair and nail growth may be increased but later decrease. Skin may be warm or cold.
F.
Stage 2Dystrophic (Ischemic)
1. Spontaneous burning and/or aching pain, more pronounced hyperpathia and or allodynia. Signs of chronic
sympathetic over activity include reduced blood flow; sudomotor changes; increased edema; cyanotic skin; muscle
wasting; decreased hair and nail growth; and osteoporosis.
G. Stage 3Atrophic
1. Signs and symptoms of this stage include pain may be less prominent; decreased hyperpathia and/or
allodynia; reduction in blood flow; skin temperature and sweating may be increased or decreased; irreversible
trophic changes in skin and integument; and pronounced muscle atrophy with contractures.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1717 (June 2011).
§2123. Definitions
A. After Sensationrefers to the abnormal persistence of a sensory perception, provoked by a stimulus even
though the stimulus has ceased.
B. Allodyniapain due to a non-noxious stimulus that does not normally provoke pain.
1. Mechanical Allodyniarefers to the abnormal perception of pain from usually non-painful mechanical
stimulation.
2. Static Mechanical Allodyniarefers to pain obtained by applying a single stimulus such as light pressure to
a defined area.
3. Dynamic Mechanical Allodyniaobtained by moving the stimulus such as a brush or cotton tip across the
abnormal hypersensitive area.
4. Thermal Allodyniarefers to the abnormal sensation of pain from usually non-painful thermal stimulation
such as cold or warmth.
C. Central Painpain initiated or caused by a primary lesion or dysfunction in the central nervous system
(CNS).
D. Central Sensitizationthe experience of pain evoked by the excitation of non-nociceptive neurons or of
nerve fibers that normally relay non-painful sensations to the spinal cord. This result when non-nociceptive afferent
neurons act on a sensitized CNS.
E. Dystoniastate of abnormal (hypo or hyper) tonicity in any of the tissues.
F.
Hyperalgesiarefers to an exaggerated pain response from a usually painful stimulation.
G. Hyperemiapresence of increased blood in a part or organ.
H. Hyperesthesia (Positive Sensory Phenomenon)includes allodynia, hyperalgesia, and hyperpathia. Elicited
by light touch, pin-prick, cold, warm vibration, joint position sensation or two-point discrimination, which is
perceived as increased or more.
I. Hyperpathiarefers to an abnormally painful and exaggerated reaction to stimulus, especially to a repetitive
stimulus, in a patient who perceives the stimulus as less intense because of an increased threshold.
J.
Hypoesthesia (also hypesthesia)diminished sensitivity to stimulation.
K. Pain Behaviorthe nonverbal actions (such as grimacing, groaning, limping, using visible pain relieving or
support devices and requisition of pain medications, among others) that are outward manifestations of pain, and
through which a person may communicate that pain is being experienced.
L. Sudomotor Changesalteration in function of sweat glands; sweat output may increase or decrease due to
changes in autonomic input to the gland.
M. Sympathetically Maintained Pain (SMP)a pain that is maintained by sympathetic efferent innervations or
by circulating catecholalmines.
N. Trophic Changestissue alterations due to interruption of nerve or blood supply; may include changes in hair
growth and texture of skin.
O. Vasomotor Changesalteration in regulation of dilation or constriction of blood vessels.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1718 (June 2011).
§2125. Initial Evaluation
A. All potential pain generators should be thoroughly investigated by complete neurological and musculoskeletal
exam and diagnostic procedures. Because CRPS-I is commonly associated with other injuries, it is essential that all
related diagnoses are defined and treated. These disturbances are typically restricted to one extremity, usually
distally, but are variable in their expression.
1. History and physical examination (Hx& PE) The history and physical exam establish the basis for
subsequent diagnostic and therapeutic procedures. When clinical evaluation findings do not complement the
findings of other diagnostic procedures, clinical findings should have preference. Before the diagnosis of CRPS-I or
CRPS-II is established, an experienced practitioner must perform a detailed neurological and musculoskeletal exam
to exclude other potentially treatable pain generators or neurological lesions.
a. Medical History. As in other fields of medicine, a thorough patient history is an important part of the
evaluation of pain. In taking such a history, factors influencing a patients’ current status can be made clear and taken
into account when planning diagnostic evaluation and treatment. History should ascertain the following elements:
i.
Causality: How did this injury occur? Was the problem initiated by a work-related injury or exposure?
ii.
Presenting symptoms:
(a). severe, generally unremitting burning and/or aching pain, and/or allodynia;
(b). swelling of the involved area;
(c). changes in skin color;
(d). asymmetry in nail and/or hair growth;
(e). abnormal sweat patterns of the involved extremity;
(f). dystonia; and/or
(g). subjective temperature changes of the affected area.
b. Pain History. The patient’s description of and response to pain is one of the key elements in treatment.
Characterization of the patient’s pain and of the patient’s response to pain is one of the key elements in treatment.
i.
Site of Pain. Localization and distribution of the pain help determine the type of pain the patient has
(i.e., central versus peripheral).
ii.
Pain Drawing/Visual Analog Scale (VAS)
iii.
Duration
iv.
Place of onset
v.
Pain Characteristics. Time of pain occurrence as well as intensity, quality and radiation give clues to
the diagnosis and potential treatment.
vi.
Response of Pain to Activity
vii.
Associated Symptoms. Does the patient have numbness or paresthesia, dysesthesia, weakness, bowel
or bladder dysfunction, decreased temperature, increased sweating, cyanosis or edema? Is there local tenderness,
allodynia, hyperesthesia or hyperalgesia?
c.
Substance Use/Abuse:
i.
alcohol use;
ii.
smoking history;
iii.
History of drug use and abuse.
iv.
Caffeine or caffeine-containing beverages.
d.
i.
Other Factors Affecting Treatment Outcome:
Compensation/disability/litigation;
ii.
Treatment Expectations. What does the patient expect from treatment: complete relief of pain or
reduction to a more tolerable level?
e. Medical Management History. Refer to the Chronic Pain Disorder Medical Treatment Guideline’s for
detailed elements when performing a review of prior medical management. In addition, history may include:
i.
Chronological review of medical records including previous medical evaluations and response to
treatment interventions.
ii.
History of diagnostic tests and results including but not limited to any response to sympathetic nerve
blocks, results of general laboratory studies, EMG and nerve conduction studies, radiological examinations,
including triple phase bone scan or thermography with autonomic stress testing.
iii.
Medications, including prescription, over-the-counter and herbal/dietary supplements.
iv.
Review of Systems check list. Determine if there is any interplay between the pain complaint and other
medical conditions.
v.
Psychosocial Functioning. Determine if the following are present: current symptoms of depression or
anxiety, evidence of stressors in the workplace or at home, and past history of psychological problems. It is
recommended that patients diagnosed with CRPS be referred for a psychosocial evaluation. All patients with CRPS
have Chronic Pain, and are likely to suffer psychosocial consequences.
vi.
Pre-existing Conditions. Treatment of these conditions is appropriate when the preexisting condition
affects recovery from chronic pain.
f. Physical Examination. Should include examination techniques applicable to those portions of the body in
which the patient is experiencing subjective symptomatology and should include:
i.
Inspection. Changes in appearance of the involved area, to include trophic changes, changes in hair and
nail growth, muscular atrophy, changes in skin turgor, swelling and color changes.
ii.
Temperature Evaluation. Palpable temperature changes may not be detectable in early disease stages,
and the examiner will generally only be able to appreciate significant temperature variations. Thermography, or
other objective testing may be necessary to display temperature asymmetries.
iii.
Motor Evaluation. Involuntary movements, dystonia or muscle weakness in the involved limb(s).
iv.
Sensory Evaluation. A detailed sensory examination is crucial in evaluating a patient with chronic pain
complaints. Presence of allodynia. Anatomic pattern of any associated sensory abnormalities to light touch, deep
touch, pain and thermal stimulation. Quantitative sensory testing may be useful.
v.
Musculoskeletal Evaluation. Presence of associated myofascial problems, such as contractures, ROM
or trigger points.
vi.
Evaluation of Nonphysiologic Findings. Determine the presence of the following: Variabilities on
formal exam including variable sensory exam, inconsistent tenderness, and or swelling secondary to extrinsic
sources; Inconsistencies between formal exam and observed abilities of range of motion, motor strength, gait and
cognitive/emotional state; and/or, observation of consistencies between pain behavior, affect and verbal pain rating,
and affect and physical re-examination.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1718 (June 2011).
§2127. Diagnostic Procedures
A. Diagnostic imaging is a generally accepted, well-established, and widely used diagnostic procedure when
specific indications, based on history and physical examination, are present. Physicians should refer to individual
OWCA guidelines for specific information about specific testing procedures.
1.
Plain Film Radiography:
a. Description. A radiological finding in CRPS may be unilateral osteoporosis; however, osteoporosis may
be absent in many cases. In CRPS-I, the osteoporosis may be rapid in progression. The disorder typically affects the
distal part of an extremity such as a hand or foot, yet intermediate joints such as the knee or elbow may be involved.
b. Results. The radiological appearance of osteoporosis has been characterized as spotty or patchy.
Although CRPS-I may exist in the absence of osteoporosis, the diagnosis of CRPS-I cannot be made solely on the
basis of radiographic appearance or the osteoporosis alone.
2.
Triple Phase Bone Scan:
a. Description. Radionucleotide imaging scintigraphy employing radio-pharmaceutical technetium coupled
to a phosphate complex has been used to help facilitate the diagnosis of CRPS-1. It was hoped that a three-phase
radionucleotide study would be selective in the face of demineralization of the bone as seen in CRPS-I. However
there are many different types of conditions that can produce osteoporosis and a triple-phase bone scan does not
distinguish between the causes of bone demineralization.
b. Results. Clinical information can be derived from each of the three phases of the bone scan following
injection. In the early course of CRPS-I, there is an increased uptake seen during Phase 1. However, in the late
course of the disease process, there can actually be a decreased uptake seen. In Phase 2, which reflects the soft tissue
vascularity, an increased diffuse uptake may be appreciated during the early course of CRPS-I. During Phase 3, one
will see a diffuse uptake of multiple bone involvement of the involved limb, reflecting the bone turnover secondary
to osteoporosis. Negative bone scans may be found in up to 40 percent of patients clinically diagnosed with CRPS-I;
however when positive it may help to confirm the diagnosis of CRPS-I.
B. Injections – diagnostic sympathetic
1. Description. Diagnostic sympathetic injections are generally accepted procedures to aid in the diagnosis of
CRPS I and II and SMP. Sympathetic blocks lack specificity for CRPS I and II. Each diagnostic injection has
inherent risk and risk versus benefit should always be evaluated when considering injection therapy. Since these
procedures are invasive, less invasive or non-invasive procedures should be considered first. Selection of patients,
choice of procedure, and localization of the level for injection should be determined by clinical information.
2. Special Considerations. Injections with local anesthetics of differing duration are required to confirm a
diagnosis. In some cases, injections at multiple levels may be required to accurately diagnose pain. Refer to
“Injections – Therapeutic” for information on specific injections.
a. Since fluoroscopic and/or CT guidance during procedures is recommended to document technique and
needle placement, an experienced physician should perform the procedure. The practitioner should have experience
in ongoing injection training workshops provided by organizations such as the International Spinal Injection Society
(ISIS) and be knowledgeable in radiation safety. In addition, practitioners should obtain fluoroscopy training and
radiation safety credentialing from their Departments of Radiology, as applicable.
3. Complications. Complications may include transient neurapraxia, nerve injury, inadvertent spinal injection,
infection, venous or arterial vertebral puncture, laryngeal paralysis, respiratory arrest, vasovagal effects, as well as
permanent neurological damage.
4. Contraindications. Absolute contraindications of diagnostic injections include: bacterial infection –
systemic or localized to region of injection, bleeding diatheses, hematological conditions, and possible pregnancy.
Relative contraindications of diagnostic injections may include: aspirin/antiplatelet therapy (drug may be held for at
least three days prior to injection).
5. Test Results. The interpretation of the test result is primarily based upon pain relief of 50 percent or greater.
The diagnostic significance of the test result should be evaluated in conjunction with clinical information and further
information can be obtained from functional reassessment performed by physical and/or occupational therapy or
from results of other diagnostic procedures following a successful block.
a. Local anesthetics of different durations of action should be considered and could take the place of doing
a "placebo" block (i.e. - procaine, lidocaine, marcaine). Pain relief should be at least 50 percent or greater for the
duration of the local anesthetic. It should be noted that with CRPS-I it is not unusual for the relief to last longer than
the duration of the local anesthetic. If a placebo block is done, the needle should not be placed down to the
sympathetic chain nor should an injection of saline be done around the sympathetic chain. Contact with the
sympathetic nerves by a needle or pressure on the chain by saline can cause a temporary sympathetic block and give
a false positive placebo test. A "sham block" would be preferable to see if the patient is a placebo responder.
Additionally, patients with definite CRPS-I can also be placebo responders. The fact that the patient responds
positively to a placebo does not mean that he/she does not have CRPS-1. It merely means that the patient is a
placebo responder. This increases the value of doing another confirmatory test.
i.
Stellate Ganglion Block. For diagnosis and treatment of sympathetic pain involving the face, head,
neck, and upper extremities secondary to CRPS-I and II. This block is commonly used for differential diagnosis and
is the preferred treatment of CRPS-I pain involving the upper extremity.
(a). For diagnostic testing, use three blocks over a 3-14 day period. For a positive response, pain relief
should be 50 greater or greater for the duration of the local anesthetic and pain relief should be associated with
functional improvement.
ii.
Lumbar Sympathetic Block. Useful for diagnosis and treatment of pain of the pelvis and lower
extremity secondary to CRPS-I and II. This block is commonly used for differential diagnosis and is the preferred
treatment of sympathetic pain involving the lower extremity. For diagnostic testing, use three blocks over a 3-14 day
period. For a positive response, pain relief should be 50 percent or greater for the duration of the local anesthetic and
pain relief should be associated with functional improvement.
iii.
Phentolamine Infusion Test. An intravenous infusion of phentoalmine, an alpha 2 blocker, which
results in generalized systemic sympatholysis. The infusion begins with intravenous saline for placebo control. For a
positive response, pain relief should be 50 percent or greater and associated with functional improvement. This test
aids in the diagnosis of Sympathetically Maintained Pain.
C. Thermography (infrared stress thermography)
1. Description. A generally accepted procedure with some evidence to support its limited use. Infrared
thermography may be useful for patients with suspected CRPS-I and II, and SMP. Thermography can distinguish
abnormal thermal asymmetry of 1.0 degree Celsius which is not distinguishable upon physical examination. It may
also be useful in cases of suspected small caliber fiber neuropathy and to evaluate patient response to sympatholytic
interventions.
2. Special Considerations. The practitioner who supervises and interprets the thermographic evaluation shall
follow recognized protocols and be board certified by one of the examining boards of the American Academy of
Medical Infrared Imaging, American Academy of Thermology, or American Chiropractic College of Thermology.
3. Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics, antipsychotics) may
interfere with autonomic testing. The pre-testing protocol which includes cessation of specific medications therapy
must be followed for accurate test results. Results of autonomic testing may be affected by peripheral
polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease, generalized autonomic failure,
or by Shy-Drager syndrome.
4.
Thermographic Tests. Functional autonomic stress testing may include any of the following methods:
a. Cold Water Stress Test (Cold Pressor Test). Paroxysmal cooling is strongly suggestive of vasomotor
instability.
b.
Warm Water Stress Test. Paroxysmal warming is strongly suggestive of vasomotor instability.
D. Autonomic test battery
1. Description. Resting skin temperature (RST), resting sweat output (RSO), and quantitative sudomotor axon
reflex test (QSART) are a recently developed test battery with some evidence to support its limited use in the
diagnosis of CRPS-I. Prior authorization is required.
2. Special Considerations. Medications with anticholinergic activity (tricyclics, cyclobenzaprine, antiemetics,
antipsychotics) may interfere with autonomic testing. Results of autonomic testing may be affected by peripheral
polyneuropathy, radiculopathy or peripheral nerve injury, peripheral vascular disease, generalized autonomic failure,
or by Shy-Drager syndrome.
3. Test Battery. These tests measure asymmetries in physiologic manifestations of autonomic activity between
an affected limb and an unaffected contralateral limb. Skin temperature reflects vasomotor activity and sweat output
measures sudomotor activity. The results of the three test components must be combined and scored. The battery of
tests must include a measurement of each component (RST, RSO, and QSART).
a. Infrared Resting Skin Temperature (RST) provides thermographic measurements between the affected
and unaffected limb. Generally, a 1° Celsius difference is significant.
b. Resting Sweat Output (RSO) measures an increase or reduction of 50 percent between the affected and
unaffected limb.
c. Quantitative Sudomotor Axon Reflex Test (QSART) measures the sweat output elicited by iontophoretic
application of acetylcholine. An increase or reduction of 50 percent between the affected and unaffected limb is
significant.
E. Other diagnostic tests not specific for crps. The following tests and procedures are not used to establish the
diagnosis of CRPS but may provide additional information. The following are listed in alphabetical order.
1. Electrodiagnostic Procedures. Electromyography (EMG) and Nerve Conduction Studies (NCS) are
generally accepted, well-established and widely used for localizing the source of the neurological symptoms and
establishing the diagnosis of focal nerve entrapments, such as carpal tunnel syndrome or radiculopathy, which may
contribute to or coexist with CRPS II (causalgia). Traditional electrodiagnosis includes nerve conduction studies,
late responses, (F-Wave, H-reflex) and electromyographic assessment of muscles with needle electrode examination.
As CRPS II occurs after partial injury to a nerve, the diagnosis of the initial nerve injury can be made by
electrodiagnostic studies. The later development of sympathetically mediated symptomatology however, has no
pathognomonic pattern of abnormality on EMG/NCS. When issues of diagnosis are in doubt, a referral or
consultation with a physiatrist or neurologist trained in electrodiagnosis is appropriate.
2. Laboratory Tests are generally accepted well-established and widely used procedures and can provide
useful diagnostic and monitoring information. They may be used when there is suspicion of systemic illness,
infection, neoplasia, or underlying rheumatologic disorder, connective tissue disorder, or based on history and/or
physical examination. Tests include, but are not limited to:
a. Complete Blood Count (CBC) with differential can detect infection, blood dyscrasias, and medication
side effects.
b. Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen
(HLA), and C-reactive protein can be used to detect evidence of a rheumatologic, infection, or connective tissue
disorder, serum protein electrophoresis.
c.
Thyroid, glucose and other tests to detect endocrine disorders.
d. Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic
bone disease.
e.
urinalysis for calcium, phosphorus, hydroxyproline, or hematuria;
f.
Liver and kidney function may be performed for baseline testing and monitoring of medications; and
g.
Toxicology Screen and/or Blood Alcohol Level if suspected drug or alcohol abuse.
3. Peripheral Blood Flow (Laser Doppler or Xenon Clearance Techniques): This is currently being evaluated
as a diagnostic procedure in CRPS-I and is not recommended by the OWCA at this time.
a.
Personality / Psychosocial / Psychiatric / Psychological Evaluation:
i.
These are generally accepted and well-established diagnostic procedures with selective use in the upper
extremity population, but have more widespread use in subacute and chronic upper extremity populations.
Diagnostic testing procedures may be useful for patients with symptoms of depression, delayed recovery, chronic
pain, recurrent painful conditions, disability problems, and for preoperative evaluation. Psychological/psychosocial
and measures have been shown to have predictive value for postoperative response, and therefore should be strongly
considered for use pre-operatively when the surgeon has concerns about the relationship between symptoms and
findings, or when the surgeon is aware of indications of psychological complication or risk factors for psychological
complication (e.g. childhood psychological trauma). Psychological testing should provide differentiation between
pre-existing conditions versus injury caused psychological conditions, including depression and posttraumatic stress
disorder. Psychological testing should incorporate measures that have been shown, empirically, to identify
comorbidities or risk factors that are linked to poor outcome or delayed recovery.
ii
Formal psychological or psychosocial evaluation should be performed on patients not making expected
progress within 6 to 12 weeks following injury and whose subjective symptoms do not correlate with objective signs
and test results. In addition to the customary initial exam, the evaluation of the injured worker should specifically
address the following areas:
(a). employment history;
(b). interpersonal relationships-both social and work;
(c). patient activities;
(d). current perception of the medical system;
(e). current perception/attitudes toward employer/job
(f). results of current treatment
(g). Risk factors and psychological comorbidities that may influence outcome and that may require
treatment.
(h). Childhood history, including history of childhood psychological trauma, abuse and family history of
disability.
iii.
Personality/psychological/psychosocial evaluations consist of two components, clinical interview and
psychological testing. Results should help clinicians with a better understanding of the patient in a number of ways.
Thus the evaluation result will determine the need for further psychosocial interventions; and in those cases,
Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis should be determined and documented. The
evaluation should also include examination of both psychological comorbidities and psychological risk factors that
are empirically associated with poor outcome and/or delayed recovery. An individual with a Ph.D., Psy.D, or
psychiatric M.D./D.O. credentials should perform initial evaluations, which are generally completed within one to
two hours. A professional fluent in the primary language of the patient is preferred. When such a provider is not
available, services of a professional language interpreter should be provided.
iv.
Frequency. One-time visit for the clinical interview. If psychometric testing is indicated as a part of the
initial evaluation, time for such testing should not exceed an additional two hours of professional time.
(a). Tests of Psychological Functioning
(i). Psychometric testing is a valuable component of a consultation to assist the physician in making a
more effective treatment plan. Psychometric testing is useful in the assessment of mental conditions, pain
conditions, cognitive functioning, treatment planning, vocational planning and evaluation of treatment effectiveness.
There is no general agreement as to which standardized psychometric tests should be specifically recommended for
psychological evaluations of chronic pain conditions. It is appropriate for the mental health provider to use their
discretion and administer selective psychometric tests within their expertise and within standards of care in the
community. Some of these tests are available in Spanish and other languages, and many are written at a 6th grade
reading level.
4. Special Tests. Tests are generally well-accepted tests and are performed as part of a skilled assessment of
the patients’ capacity to return to work, strength capacity, and or physical work demands classifications and
tolerance. Tests include Computer-Enhanced Evaluations, Functional Capacity Evaluation (FCE), Jobsite
Evaluation, Vocational Assessment, and Work Tolerance Screening. Refer to the Chronic Pain Medical Treatment
Guidelines for detailed information and frequency of each special testing procedure.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1719 (June 2011).
§2129. Diagnosis of CRPS
A. Diagnostic Components of CRPS-I (RSD)
1. Subjective Complaints. Complaint of pain, usually burning or aching pain and out of proportion to
identified pathology. May be sharp, or lancinating. Frequently is present without provocation or movement.
2.
Physical Findings:
a.
Swelling, generally unilateral and variable in presentation.
b. Vasomotor signs – Unilateral. Initial extremity warming early on, coldness of extremity as condition
progresses. Discoloration of skin usually darker blue or purple, may be mottled, may be paler.
c.
Sudomotor sign – Increased sweating of the involved extremity.
d. Trophic Changes – Coarse, thick hair, later may be sparse; nails brittle, ridged, may grow faster initially,
later grow more slowly; skin is smooth, shiny; digits tapered (pencil pointing); joints stiff with decreased ROM;
muscle wasting; motor disturbances; increased physiological tremor, dystonia.
3.
Diagnostic Testing Procedures:
a.
x-rays of both extremities;
b.
triple phase bone scan;
c.
sympathetic blocks;
d.
infrared thermogram;
e.
autonomic test battery.
B. Diagnostic Criteria for CRPS
1.
CRPS-I (RSD):
a.
Patient complains of pain, usually diffuse burning or aching;
b. Patient has physical findings on examination of at least vasomotor and/or sudomotor signs. Allodynia
and/or trophic changes add strength to the diagnosis of CRPS-I; and
c. At least two diagnostic testing procedures are positive. Even the most sensitive tests can have false
negatives. The patient can still have CRPS-I, if clinical signs are strongly present. In patients with continued signs
and symptoms of CRPS-I, further diagnostic testing may be appropriate.
2.
CRPS-II (causalgia):
a.
Patient complains of pain;
b.
Documentation of peripheral nerve injury with pain initially in the distribution of the injured nerve;
c. Patient has physical findings on examination of at least vasomotor and/or sudomotor signs. Allodynia
and/or trophic changes add strength to the diagnosis of CRPS-II; and
d. At least two diagnostic testing procedures are positive. Even the most sensitive tests can have false
negatives. The patient can still have CRPS-II, if clinical signs are strongly present. In patients with continued signs
and symptoms of CRPS-II, further diagnostic testing may be appropriate.
3.
Sympathetically Mediated Pain (SMP):
a.
Patient complains of pain;
b.
Usually does not have clinically detectable vasomotor or sudomotor signs; and
c.
Has pain relief with sympathetic blocks.
4.
Not CRPS:
a.
Patient complains of pain;
b.
May or may not have vasomotor or sudomotor signs;
c.
No relief with sympathetic blocks; and
d.
No more than one other diagnostic test procedure is positive.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1722 (June 2011).
§2131. Therapeutic Procedures – Non-Operative
A. Non-operative therapeutic rehabilitation is applied to patients with CRPS or SMP who experience chronic and
complex problems of de-conditioning and functional disability. Treatment modalities may be utilized sequentially or
concomitantly depending on chronicity and complexity of the problem, and treatment plans should always be based
on a diagnosis utilizing appropriate diagnostic procedures.
B. Before initiation of any therapeutic procedure, the authorized treating physician, employer and insurer must
consider these important issues in the care of the injured worker:
1. Patients undergoing therapeutic procedure(s) should be released or returned to modified or restricted duty
during their rehabilitation at the earliest appropriate time. Refer to Return-to-Work for detailed information.
2. Reassessment of the patient’s status in terms of functional improvement should be documented after each
treatment. If patients are not responding within the recommended time periods, alternative treatment interventions,
further diagnostic studies or consultations should be pursued. Continued treatment should be monitored using
objective measures such as:
a.
Return to work or maintaining work status.
b.
Fewer restrictions at work or performing or limitations in activities of daily living (ADL).
c.
Decrease in usage of medications.
d.
Measurable functional gains, such as increased range of motion or documented increase in strength.
3. Clinicians should provide and document education to the patient. No treatment plan is complete without
addressing issues of individual and/or group patient education as a means of facilitating self-management of
symptoms.
4.
Psychological or psychosocial screening should be performed on all chronic pain patients.
C. The following procedures are listed in alphabetical order.
1. Acupuncture is an accepted and widely used procedure for the relief of pain and inflammation and there is
some scientific evidence to support its use. Credentialed practitioners must perform acupuncture evaluations, with
experience in evaluation and treatment of chronic pain patients. The exact mode of action is only partially
understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the
brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an
alternative or in addition to traditional Western pharmaceuticals. It is commonly used when pain medication is
reduced or not tolerated. It may be used as an adjunct to physical rehabilitation, surgical intervention, and or as part
of multidisciplinary treatment to hasten the return of functional activity. Acupuncture should be performed by
licensed practitioners.
a. Refer to the Chronic Pain Medical Treatment guideline’s for detailed information on acupuncture and
timeframe parameters.
2. Biofeedback is a generally well-accepted form of behavioral medicine that helps patients learn selfawareness and self-regulation skills for the purpose of gaining greater control of their physiology. Biofeedback
treatment is intended to assist patients in managing stress-related psychophysiological reactions that may arise as a
reaction to organic pain, or which may cause pain. The biofeedback specialist may utilize a variety of interventions
for teaching physiological self-management. Biological feedback may then be provided through mechanisms
ranging from simple devices to electronic instrumentation, and displayed or fed back to the patient visually,
auditorially, or tactilely. This enables the patient to identify and refine effective interventions.
a. The application of biofeedback to patients with CRPS is not well researched. However, based on CRPS
symptomology, temperature or skin conductance feedback modalities may be of particular interest. Refer to the
Chronic Pain Medical Treatment Guideline’s for detailed information on biofeedback and time parameters.
3. Disturbances of sleep are common in chronic pain. Although primary insomnia may accompany pain as an
independent comorbid condition, it more commonly occurs, secondary to the pain condition itself. Exacerbations of
pain often are accompanied by exacerbations of insomnia; the reverse can also occur. Sleep laboratory studies have
shown disturbances of sleep architecture in pain patients. Loss of deep slow-wave sleep and increase in light sleep
occur and sleep efficiency, the proportion of time in bed spent asleep, is decreased. These changes are associated
with patient reports of non-restorative sleep.
a. Many chronic pain patients develop behavioral habits that exacerbate and maintain sleep disturbances.
Excessive time in bed, irregular sleep routine, napping, low activity and worrying in bed are all maladaptive
responses that can arise in the absence of any psychopathology. There is some evidence that behavioral
modification, such as patient education and group or individual counseling, can be effective in reversing the effects
of insomnia. Behavioral modifications are easily implemented and can include:
i.
Maintaining a regular sleep schedule, retiring and rising at approximately the same time on weekdays
and weekends.
ii.
Avoiding daytime napping.
iii.
Avoiding caffeinated beverages after lunchtime
iv.
Making the bedroom quiet and comfortable, eliminating disruptive lights, sounds television sets, and
keeping a bedroom temperature of about 65°F.
v.
vi.
Avoiding alcohol or nicotine within two hours of bedtime.
Avoiding large meals within two hours of bedtime.
vii.
Exercising vigorously during the day, but not within two hours of bedtime, since this may raise core
temperature and activate the nervous system.
viii.
Associating the bed with sleep and sexual activity only, using other parts of the home for television,
reading and talking on the telephone.
ix.
Leaving the bedroom when unable to sleep for more than 20 minutes, retuning to the bedroom when
ready to sleep again.
b.
These modifications should be undertaken before sleeping medication is prescribed.
4. Injections — therapeutic. When considering the use of injections in CRPS management, the treating
physician must carefully consider the inherent risks and benefits. First, it is understood that these injections are
seldom meant to be “curative” but may have diagnostic or prognostic qualities and when used for therapeutic
purposes they are employed in conjunction with other treatment modalities for maximum benefit. Second, education
of the patient should include the proposed goals of the injections, expected gains, risks or complications, and
alternative treatment. Lastly, reassessment of the patient’s status in terms of functional improvement should be
documented after each injection and/or series of injections.
a.
Any continued use of injections should be monitored using objective measures such as:
i.
Return to work or maintaining work status.
ii.
Fewer restrictions at work or when performing activities of daily living (ADL).
iii.
Decrease in usage of medications.
iv.
Measurable functional gains, such as increased range of motion or documented increase in strength.
(a). Visual analog scales (VAS) provide important subjective data but are not an appropriate measure of
function.
(b). The physician must be aware of the possible placebo effect as well as the long-term effects of
injections related to the patient’s physical and mental status. Strict adherence to contraindications, both absolute and
relative, may prevent potential complications. Subjecting the patient to potential risks, i.e., needle trauma, infection,
nerve injury, or systemic effects of local anesthetics and corticosteroids, must be considered before the patient
consents to such procedures.
b.
Sympathetic Injections:
i.
Description. Sympathetic injections are generally accepted, well-established procedures. They include
stellate ganglion blocks, lumbar sympathetic, and intravenous regional (Bier) blocks. Regional blocks frequently use
bretylium with additional agents (narcotics and or anti-inflammatory drugs). There is some evidence that bretylium
reduces pain intensity. It is recommended that all patients receiving therapeutic blocks participate in an appropriate
exercise program that may include a functionally directed rehabilitation program.
ii.
Indications. Pain relief and functional improvement from previous diagnostic or therapeutic blocks.
iii.
Special Considerations. Except for Bier blocks, fluoroscopic and/or CT guidance during procedures is
recommended to document technique and needle placement; an experienced physician should perform the
procedure. The practitioner should participate in ongoing injection training workshops provided by organizations
such as the International Spinal Injection Society (ISIS) and be knowledgeable in radiation safety. In addition,
practitioners should obtain fluoroscopy training and radiation safety credentialing from their Departments of
Radiology, as applicable.
iv.
Complications may include transient neurapraxia, nerve injury, inadvertent spinal injection, infection,
venous or arterial vertebral puncture, laryngeal paralysis, respiratory arrest, vasovagal effects, as well as permanent
neurologic damage.
v.
Contraindications. Absolute contraindications of therapeutic injections include:
(a). bacterial infection – systemic or localized to region of injection,
(b). bleeding diatheses,
(c). hematological conditions, and
(d). possible pregnancy. Relative contraindications of therapeutic
aspirin/antiplatelet therapy (drug may be held for at least 3 days prior to injection).
injections
may
include:
vi.
Treatment Parameters. To be effective as a treatment modality, the patient should be making
measurable progress in their rehabilitation program and should be achieving an increasing or sustained duration of
relief between blocks. If appropriate outcomes are not achieved, changes in treatment should be undertaken.
(a). Time to produce effect: one to three blocks
(b). Frequency: Variable, depending upon duration of pain relief and functional gains. During the first
two weeks of treatment, blocks may be provided every three to five days, based on patient response. After the first
two weeks, blocks may be given weekly with tapering for a maximum of seven injections over six weeks.
(c). Optimum duration: three months.
(d). Maximum duration: three to four months for initial treatment. For the use of blocks during
maintenance care, refer to the Maintenance Care section for treatment parameters.
(e). Trigger Point Injections: May be appropriate when myofascial trigger points are present on
examination. Refer to chronic pain guidelines for treatment parameters.
(f). Peripheral Nerve Blocks: May be appropriate when peripheral nerve pathology is identified. Refer to
chronic pain guidelines for treatment parameters.
(g). Intravenous lidocaine: May be used as a prognostic indicator for the use of mexilitine. It is
infrequently used as a therapeutic treatment.
5. Interdisciplinary rehabilitation programs are the gold standard of treatment for individuals with chronic
pain who have not responded to less intensive modes of treatment. In addition, there are current studies to support
the use of pain programs. There is strong evidence that interdisciplinary programs improve function in chronic pain
and moderate evidence that these programs decrease pain in these patients.
a. These programs should assess the impact of pain and suffering on the patient’s medical, physical,
psychological, social, and/or vocational functioning. In general, interdisciplinary programs deal with irreversible,
painful musculoskeletal, neurological, and other chronic painful disorders and psychological issues, including drug
dependence, high levels of stress and anxiety, failed surgery and pre-existing or latent psychopathology. The number
of professions involved in the team in a chronic pain program may vary due to the complexity of the needs of the
person served. The OWCA recommends consideration of referral to an interdisciplinary program within 6 months
post-injury in patients with delayed recovery unless surgical interventions or other medical complications intervene.
b. Chronic pain patients need to be treated within a continuum of treatment intensity. Chronic pain
programs are available with services provided by a coordinated interdisciplinary team within the same facility
(formal) or as coordinated by the authorized treating physician (informal). Formal programs are able to provide
coordinated, high intensity level of services and are recommended for most chronic pain patients who have received
multiple therapies during acute management. Informal programs offer a lesser intensity of service and may be
considered for patients who are currently employed, those who cannot attend all day programs, those with language
barriers, or those living in areas not offering formal programs. Before treatment has been initiated, the patient,
physician, and insurer should agree on treatment approach, methods, and goals. Generally the type of program
needed will depend on the degree of impact the pain has had on the patient’s medical, physical, psychological, social
and/or vocational functioning.
c. When referring a patient for formal interdisciplinary pain rehabilitation or Work Hardening programs, the
OWCA recommends the programs be Commission on Accreditation of Rehabilitation Facilities (CARF) eligible
and/or certified. CARF eligibility or certification ensures that programs meet specific care standards of design and
efficacy.
d. Inpatient Pain Rehabilitation Programs are rarely needed but may be necessary for patients with any of
the following conditions: High risk for medical instability; Moderate to severe impairment of physical/functional
status; Moderate to severe pain behaviors; Moderate impairment of cognitive and/or emotional status; Dependence
on medications from which he or she needs to be withdrawn; and the need for 24-hour supervised nursing.
e. Interdisciplinary pain programs, whether formal or informal, should be comprised of the following
dimensions:
i.
Communication. To ensure positive functional outcomes, communication between the patient, insurer
and all professionals involved must be coordinated and consistent. Any exchange of information must be provided to
all professionals, including the patient. Care decisions would be communicated to all.
ii.
Documentation. Through documentation by all professionals involved and/or discussions with the
patient, it should be clear that functional goals are being actively pursued and measured on a regular basis to
determine their achievement or need for modification.
iii.
Treatment Modalities. Use of modalities may be necessary early in the process to facilitate compliance
with and tolerance to therapeutic exercise, physical conditioning, and increasing functional activities. Active
treatments should be emphasized over passive treatments. Active treatments should encourage self-coping skills and
management of pain, which can be continued independently at home or at work. Treatments that can foster a sense
of dependency by the patient on the caregiver should be avoided. Treatment length should be decided based upon
observed functional improvement. For a complete list of Active and Passive Therapies, refer to those Subparagrahps
of this guideline. All treatment timeframes may be extended based upon the patient’s positive functional
improvement.
iv.
Therapeutic Exercise Programs. There is strong evidence that these programs, including aerobic
conditioning and strengthening, are superior to treatment programs that do not include exercise. There is no
sufficient evidence to support the recommendation of any particular exercise regimen over any other exercise
regimen. A therapeutic exercise program should be initiated at the start of any treatment rehabilitation. Such
programs should emphasize education, independence, and the importance of an on-going exercise regime.
v.
Return-to-work. The authorized treating physician should continually evaluate the patient for their
potential to return to work. When return-to-work is an option, it may be appropriate to implement a Work Hardening
Program (as described in this section). For patients currently employed, efforts should be aimed at keeping them
employed. For more specific information regarding return-to-work, refer to the Return-to-work section in this
guideline.
vi.
Patient Education. Patients with pain need to re-establish a healthy balance in lifestyle. All providers
should educate patients on how to overcome barriers to resuming daily activity, including pain management,
decreased energy levels, financial constraints, decreased physical ability, and change in family dynamics.
vii.
Psychosocial Evaluation and Treatment. Psychosocial evaluation should be initiated, if not previously
done. Providers of care should have a thorough understanding of the patient’s personality profile; especially if
dependency issues are involved. Psychosocial treatment may enhance the patient’s ability to participate in pain
treatment rehabilitation, manage stress, and increase their problem-solving and self-management skills.
viii.
Vocational Assistance. Vocational assistance can define future employment opportunities or assist
patients in obtaining future employment. Refer to Return-to-work section for detailed information.
f. Interdisciplinary programs are characterized by a variety of disciplines that participate in the assessment,
planning, and/or implementation of the treatment program. These programs are for patients with greater levels of
perceived disability, dysfunction, de-conditioning and psychological involvement. The following programs are listed
in order of decreasing intensity.
i.
Formal Rehabilitation Programs:
(a). Interdisciplinary Pain Rehabilitation. An Interdisciplinary Pain Rehabilitation Program provides
outcomes-focused, coordinated, goal-oriented interdisciplinary team services to measure and improve the
functioning of persons with pain and encourage their appropriate use of health care system and services. The
program can benefit persons who have limitations that interfere with their physical, psychological, social, and/or
vocational functioning. The program shares information about the scope of the services and the outcomes achieved
with patients, authorized providers, and insurers.
(b). The interdisciplinary team maintains consistent integration and communication to ensure that all
interdisciplinary team members are aware of the plan of care for the patient, are exchanging information, and
implement the plan of care. The team members make interdisciplinary team decisions with the patient and then
ensure that decisions are communicated to the entire care team.
(c). The medical director of the pain program should be board certified in his or her specialty area, have
at least two years full-time experience in an interdisciplinary pain rehabilitation program, and ideally be board
certified in pain management. Individuals who assist in the accomplishment of functional, physical, psychological,
social and vocational goal must include, at the least, a medical director, pain physician(s), psychologist, Biofeedback
Therapist, Occupational Therapist, Physical Therapist, and Registered Nurse. Other disciplines on the team may
include, but are not limited to, case manager, exercise physiologist, psychiatrist, and/or nutritionist.
(i). Time to produce effect: three to four weeks
(ii). Frequency: No less than five hours/day, five days/week
(iii). Optimum duration: three to four weeks five times a week, followed by six to nine weeks of
follow-up one to three times a week.
(iv). Maximum duration: Four months, including follow-up. Periodic review and monitoring thereafter
on an as needed basis, is founded upon the documented maintenance of functional gains.
(d). Work Hardening is an interdisciplinary program addressing a patient’s employability and return-towork. It includes a progressive increase in the number of hours per day that a patient completes work simulation
tasks until the patient can tolerate a full workday. A full workday is case specific and is defined by the previous
employment of the patient. This is accomplished by addressing the medical, psychological, behavioral, physical,
functional, and vocational components of employability and return-to-work.
(e). The interdisciplinary team should, at a minimum, be comprised of a qualified medical director who
is board certified with documented training in occupational rehabilitation, team physicians having experience in
occupational rehabilitation, occupational therapy, physical therapy, case manager, and psychologist. As appropriate,
the team may also include: chiropractor, RN, or vocational specialist.
(i). Time to produce effecttwo weeks
(ii). Frequencytwo to five visits per week, up to eight hours/day.
(iii). Optimum durationtwo to four weeks
(iv). Maximum durationsix weeks. Participation in a program beyond six weeks must be
documented with respect to need and the ability to facilitate positive symptomatic or functional gains.
ii.
Informal Rehabilitation Program. A coordinated interdisciplinary pain rehabilitation program is one in
which the authorized treating physician coordinates all aspects of care. This type of program is similar to the formal
programs in that it is goal oriented and provides interdisciplinary rehabilitation services to manage the needs of the
patient in the following areas: functional, medical, physical, psychological, social, and vocational.
(a). This program is different from a formal program in that it involves lesser frequency and intensity of
services/treatment. Informal rehabilitation is geared toward those patients who do not need the intensity of service
offered in a formal program or who cannot attend an all-day program due to employment, daycare, language or other
barriers.
(b). Patients should be referred to professionals experienced in outpatient treatment of chronic pain. The
OWCA recommends the authorized treating physician consult with physicians experienced in the treatment of
chronic pain to develop the plan of care.
(i). Time to produce effect: three to eight weeks
(ii). Frequency: two to six hours per day, two to five days each week.
(iii). Optimum duration: 6 to 12 weeks, including follow-up.
(iv). Maximum duration: Four months, including follow-up. Periodic review and monitoring thereafter
on an as needed basis, is founded upon the documented maintenance of functional gains.
6. Medications. There is no single formula for pharmacological treatment of patients with chronic
nonmalignant pain. A thorough medication history, including use of alternative and over the counter medications,
should be performed at the time of the initial visit and updated periodically. Appropriate application of
pharmacological agents depends on the patient’s age, past history (including history of substance abuse), drug
allergies, and the nature of all medical problems. It is incumbent upon the physician to thoroughly understand
pharmacological principles when dealing with the different drug families and their respective side effect,
bioavailability profiles and primary reason for each medication’s usage.
a. Control of chronic non-malignant pain is expected to involve the use of medication. Strategies for
pharmacological control of pain cannot be precisely specified in advance. Rather, drug treatment requires close
monitoring of the patient’s response to therapy, flexibility on the part of the prescriber, and a willingness to change
treatment when circumstances change. Many of the drugs discussed in the medication section were licensed for
indications other than analgesia, but are effective in the control of many types of chronic pain.
b. All medications should be given an appropriate trial in order to test for therapeutic effect. Trials of
medication requiring specific therapeutic drug levels may take several months to achieve, depending upon the halflife of the drug. It is recommended that patients with CRPS be maintained on drugs that have the least serious side
effects. For example, patients need to be tried or continued on acetaminophen and or antidepressant medications
whenever feasible as part of their overall treatment for chronic pain. It is recommended that use of opioid analgesic
and sedative hypnotic medications in chronic pain patients be used in a very limited manner, with total elimination
desirable whenever clinically feasible.
c. For the clinician to interpret the following material, it should be noted that: drug profiles listed are not
complete; dosing of drugs will depend upon the specific drug, especially for off-label use; and not all drugs within
each class are listed, and other drugs within the class may be appropriate. Clinicians should refer to informational
texts or consult a pharmacist before prescribing unfamiliar medications or when there is a concern regarding drug
interactions.
d.
The following drug classes are listed in alphabetical order, not in order of suggested use.
i.
Anticonvulsants. Although the mechanism of action of anticonvulsant drugs in neuropathic pain states
remains to be fully defined, they appear to act as nonselective sodium channel blocking agents. A large variety of
sodium channels are present in nervous tissue, and some of these are important mediators of nociception, as they are
found primarily in unmyelinated fibers and their density increases following nerve injury. While the
pharmacodynamic effects of the various anticonvulsant drugs are similar, the pharmacokinetic effects differ
significantly. Carbamazepine has important effects as an inducer of hepatic enzymes and may influence the
metabolism of other drugs enough to present problems in patients taking more than one drug. Gabapentin and
oxcarbazepine, by contrast, are relatively non-significant enzyme inducers, creating fewer drug interactions.
Because anticonvulsant drugs may have more problematic side-effect profiles, their use should usually be deferred
until antidepressant drugs have failed to relieve pain.
(a). Gabapentin (Neurontin)
(i). Description – Structurally related to gamma aminobutyric acid (GABA) but does not interact with
GABA receptors.
(ii). Indications – Neuropathic pain.
(iii). Relative Contraindications – Renal insufficiency.
(iv). Dosing and Time to Therapeutic Effect – Dosage may be increased over several days.
(v). Major Side Effects – Confusion, sedation.
(vi). Drug Interactions – Oral contraceptives, cimetidine, antacids.
(vii).
Recommended Laboratory Monitoring – Renal function.
ii.
Antidepressants are classified into a number of categories based on their chemical structure and their
effects on neurotransmitter systems. Their effects on depression are attributed to their actions on disposition of
norepinephrine and serotonin at the level of the synapse; although these synaptic actions are immediate, the
symptomatic response in depression is delayed by several weeks. When used for chronic pain, the effects may in
part arise from treatment of underlying depression, but may also involve additional neuromodulatory effects on
endogenous opioid systems, raising pain thresholds at the level of the spinal cord.
(a). Pain responses may occur at lower drug doses with shorter times to symptomatic response than are
observed when the same compounds are used in the treatment of mood disorders. Neuropathic pain, diabetic
neuropathy, post-herpetic neuralgia, and cancer-related pain may respond to antidepressant doses low enough to
avoid adverse effects that often complicate the treatment of depression.
(i). Tricyclics (e.g., amitryptiline [Elavil], nortriptyline [Pamelor, Aventyl], doxepin [Sinequan,
Adapin])
[a]. Description – Serotonergics, typically tricyclic antidepressants (TCAs), are utilized for their
serotonergic properties as increasing CNS serotonergic tone can help decrease pain perception in non-antidepressant
dosages. Amitriptyline is known for its ability to repair Stage 4 sleep architecture, a frequent problem found in
chronic pain patients and to treat depression, frequently associated with chronic pain.
[b]. Indications – Chronic musculoskeletal and/or neuropathic pain, insomnia. Second line drug
treatment for depression.
[c]. Major Contraindications – Cardiac disease or dysrhythmia, glaucoma, prostatic hypertrophy,
seizures, suicide risk.
[d]. Dosing and Time to Therapeutic Effect – Varies by specific tricyclic. Low dosages are
commonly used for chronic pain and/or insomnia.
[e]. Major Side Effects – Anticholinergic side effects including, but not limited to, dry mouth,
sedation, orthostatic hypotension, cardiac arrhythmia, weight gain.
[f]. Drug Interactions – Tramadol (may cause seizures), Clonidine,
sympathomimetics, valproic acid, warfarin, carbamazepine, bupropion, anticholinergics, quinolones.
cimetidine,
[g]. Recommended Laboratory Monitoring – Renal and hepatic function. Electrocardiogram
(EKG) for those on high dosages or with cardiac risk.
iii.
Hypnotics and Sedatives: Sedative and hypnotic drugs decrease activity, induce drowsiness, and
moderate agitation. Many drugs produce these effects incidental to their usual intended effects, similar to the side
effects of many antihistamines and antidepressants. Due to the habit-forming potential of the benzodiazepines and
other drugs found in this class, they are not routinely recommended but may be useful in some patients with chronic
pain.
(a). Most insomnia in chronic pain patients should be managed primarily though behavioral
interventions with medications as secondary measures (refer to Disturbances of Sleep).
(i). Zaleplon (Sonata):
[a]. descriptiona nonbenzodiazepine hypnotic;
[b]. indicationsinsomnia;
[c]. dosing and time to therapeutic effecttime of onset is 30 to 60 minutes. Due to rapid
elimination, may be taken as little as 4 hours before awakening;
[d]. major side effectsdizziness, dose-related amnesia;
[e]. drug interactionsincreases sedative effect of other CNS depressant drugs. Use low dose if
on cimetidine;
[f].
recommended laboratory monitoringhepatic function.
(ii). Zolpidem (Ambien)
[a]. Description – A nonbenzodiazepine hypnotic, which does not appear to cause rebound
insomnia. It has little respiratory depression and insignificant anxiolytic or muscle relaxant activity.
[b]. Indications – Short-term use for insomnia
[c]. Time to Produce Therapeutic Effect – Onset of action is 30 to 60 minutes
[d]. Major Side Effects – Dizziness, dose-related amnesia.
[e]. Drug Interactions – Increases sedative effect of other CNS depressant drugs.
[f].
Recommended Laboratory Monitoring – Hepatic function.
iv.
Opioids are the most powerful analgesics. Their use in acute pain and moderate to severe cancer pain is
well accepted. Their use in chronic nonmalignant pain, however, is fraught with controversy and lack of scientific
research.
(a). Opioids include some of the oldest and most effective drugs used in the control of severe pain. The
discovery of opioid receptors and their endogenous peptide ligands has led to an understanding of effects at the
binding sites of these naturally occurring substances. Most of their analgesic effects have been attributed to their
modification of activity in pain pathways within the central nervous system; however, it has become evident that
they also are active in the peripheral nervous system. Activation of receptors on the peripheral terminals of primary
afferent nerves can mediate antinociceptive effects, including inhibition of neuronal excitability and release of
inflammatory peptides. Some of their undesirable effects on inhibiting gastrointestinal motility are peripherally
mediated by receptors in the bowel wall.
(b). The central nervous system actions of these drugs account for much of their analgesic effect and for
many of their other actions, such as respiratory depression, drowsiness, mental clouding, reward effects, and habit
formation. With respect to the latter, it is crucial to distinguish between three distinct phenomena: tolerance,
dependence, and addiction.
(c). Tolerance refers to a state of adaptation in which exposure to a drug over time causes higher doses of
that drug to be required in order to produce the same physiologic effect.
(d). Dependence refers to a set of disturbances in body homeostasis that leads to withdrawal symptoms,
which can be produced with abrupt discontinuation, rapid reduction, decreasing blood levels, and /or by
administration of an antagonist.
(e). Addiction is a primary, chronic, neurobiologic disease, with genetic, psychological, and
environmental factors influencing its development and manifestations. It is a behavioral pattern of drug craving and
seeking which leads to a preoccupation with drug procurement and use.
(f). Tolerance and dependence are physiological phenomena, are expected with the continued
administration of opioids, and should not deter physicians from their appropriate use.
(g). The use of opioids is well accepted in treating cancer pain, where nociceptive mechanisms are
generally present due to ongoing tissue destruction, expected survival may be short, and symptomatic relief is
emphasized more than functional outcomes. In chronic non-malignant pain, by contrast, tissue destruction has
generally ceased, meaning that central and neuropathic mechanisms frequently overshadow nociceptive processes.
Expected survival in chronic pain is relatively long and return to a high level of function is a major goal of
treatment. Therefore, approaches to pain developed in the context of malignant pain may not be transferable to
chronic non-malignant pain.
(h). In most cases, analgesic treatment should begin with acetaminophen, aspirin, and NSAIDs. While
maximum efficacy is modest, they may reduce pain sufficiently to permit adequate function. When these drugs do
not satisfactorily reduce pain, opioids for moderate to moderately severe pain may be added to (not substituted for)
the less efficacious drugs.
(i). Consultation or referral to a pain specialist should be considered when the pain persists but the
underlying tissue pathology is minimal or absent and correlation between the original injury and the severity of
impairment is not clear. Consider consultation if suffering and pain behaviors are present and the patient continues
to request medication, or when standard treatment measures have not been successful or are not indicated.
(i). General Indications – There must be a clear understanding that opioids are to be used for a limited
term in the first instance (see trial indications below), that their use is contingent upon certain obligations or goals
being met by the patient, e.g., return to work, and the patient understands that there may be drug screening to ensure
compliance.
(ii). Therapeutic Trial Indications – A therapeutic trial of opioids should not be employed unless the
patient has begun a rehabilitation program. Once this criterion has been met, opioids would be indicated when a
patient meets the following:
[a]. The failure of pain management alternatives, including active therapies, cognitive behavioral
therapy, pain self-management techniques, and other appropriate medical techniques.
[b]. Physical and psychosocial assessment, performed by two specialists with one being the
authorized treating physician.
[c]. Informed, written, witnessed consent by the patient.
[i].In addition, there should be documentation of sustained improvement of pain control and/or
functional status, including return to work, with use of opioids. Frequent follow-up at least every two to four weeks
may be necessary to titrate dosage and assess clinical efficacy.
(iii). On-Going, Long-Term Management – Actions should Include:
[a]. Prescriptions from a single practitioner.
[b]. Ongoing review and documentation of pain relief, functional status, appropriate medication
use, and side effects.
[c]. Ongoing effort to gain improvement of social and physical function as a result of pain relief.
[d]. Contract detailing reasons for termination of supply, with appropriate tapering of dose.
[e]. Use of random drug screening, as deemed appropriate by the prescribing physician.
[f]. Use of more than two opioids. A long acting opioid for maintenance of pain relief and a short
acting opioid for limited rescue use when pain exceeds the routine level. If more than two opioids are prescribed for
long-term use a second opinion from specialist who is Board Certified in Neurology, Physical Medicine and
Rehabilitation, or Anesthesiology with recognized training and/or certification in pharmacological pain management
is strongly recommended.
[g].Use of acetaminophen-containing medications in patients with liver disease should be limited;
and
[h]. Continuing review of overall situation with regard to nonopioid means of pain control.
[i]. Inpatient treatment in complex cases. Refer to Interdisciplinary Rehabilitation Programs for
detailed information on in-patient criteria.
(iv). Relative Contraindications – Extreme caution should be used in prescribing controlled substances
for workers with one or more “relative contraindications”:
[a]. History of alcohol or other substance abuse, or a history of chronic, high-dose benzodiazepine
use;
[b]. Off work for more than six months;
[c]. Severe personality disorder.
(v). General Contraindications –
[a]. Active alcohol or other substance abuse.
[b]. Untreated mood or psychotic disorders (e.g., depression).
[c]. Decreased physical or mental function with continued opioid use.
[d]. Addictive behaviors. Warning signs include:
[i].Preoccupation with drugs;
[ii].Refusal to participate in medication taper.
[iii].Reporting that nothing but a specific opioid works;
[iv].Strong preference for short-acting over long-acting opioids.
[v].Use of multiple prescribers and pharmacies.
[vi].Use of street drugs or other patients drugs.
[vii].Not taking medications as prescribed.
[viii].Loss of medications more than once; and/or
[ix].Criminal behaviors to obtain drugs, i.e., forged prescriptions.
(vi). Dosing and Time to Therapeutic Effect. Oral route is the preferred route of analgesic
administration because it is the most convenient and cost-effective method of administration. When patients cannot
take medications orally, rectal and transdermal routes should be considered because they are also relatively
noninvasive.
(vii).
Major Side Effects. There is great individual variation in susceptibility to opioid-induced
side effects and clinicians should monitor for these potential side effects. Common initial side effects include
nausea, vomiting, drowsiness, unsteadiness, and confusion. Occasional side effects include dry mouth, sweating,
pruritus, hallucinations, and myoclonus. Rare side effects include respiratory depression and psychological
dependence. Constipation and nausea/vomiting are common problems associated with long-term opioid
administration and should be anticipated, treated prophylactically, and monitored constantly.
(viii).
Drug Interactions. Patients receiving opioid agonists should not be given a mixed
agonist-antagonist (pentazocine [Talwin], butorphanol [Stadol]) because doing so may precipitate a withdrawal
syndrome and increase pain.
(ix). Recommended Laboratory Monitoring. Primary laboratory monitoring is recommended for
acetaminophen/aspirin/ibuprofen combinations (renal and liver function, blood dyscrasias). May perform urine and
or blood drug screen if suspect use of other narcotics or lack of compliance with full medication regimen.
{x}. Patient Physician Contracts. All patients on chronic opioids should have an informed, written,
witnessed consent. The contract should discuss side effects of opioids, results of use in pregnancy, inability to refill
lost or missing medication, withdrawal symptoms, requirement for drug testing, and necessity of tapering.
(xi). Potentiating Agents. Some medications appear to potentiate the analgesic effects of opioids.
Dextromethorphan is available as a nonopioid non-prescription antitussive agent in numerous cough and cold
remedies. It antagonizes n-methyl-d-aspartate receptors involved in central sensitization of pain pathways. It may
exert some morphine sparing effects in patients taking morphine, but its activity as an analgesic in neuropathic pain
is likely to be weak. It is well tolerated in most patients. Because the patient profiles that might predict response to
dextromethorphan are undefined, its use in chronic pain must be empirically tried on an individual basis.
Diphenhydramine and hydroxyzine (atarax, vistaril) are antihistamines, which act at H 1 receptors to alleviate
allergic symptoms and produce somnolence. Diphenhydramine is a component of some non-prescription sleeping
preparations. Their use in potentiating the effects of analgesic drugs is not clearly defined, but it may be used
empirically for this purpose.
v.
Topical Drug Delivery:
(a). Description. Topical medications, such as ketamine and capsacin, may be an alternative treatment for
neuropathic disorders and is an acceptable form of treatment in selected patients although there is no literature
addressing its use in patients with CRPS.
(b). Indications. Pain. Patient selection must be rigorous to select those patients with the highest
probability of compliance.
(c). Dosing and Time to Therapeutic Effect. It is necessary that all topical agents be used with strict
instructions for application as well as maximum number of applications per day to obtain the desired benefit and
avoid potential toxicity.
(d). Side Effects. Localized skin reactions may occur, depending on drug.
vi.
Other Agents:
(a). Tramadol (Ultram)
(i). Description. An opioid partial agonist that is generally well tolerated, does not cause GI ulceration,
or exacerbate hypertension or congestive heart failure.
(ii). Indications. Mild to moderate pain relief. This drug has been shown to provide pain relief
equivalent to that of commonly prescribed NSAIDs.
(iii). Contraindications. Use cautiously in patients who have a history of seizures or who are taking
medication that may lower the seizure threshold, such as monoamine oxidase (MAO) inhibitors, selective serotonin
reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs). Not recommended in those with prior opioid
addiction.
(iv). Side Effects. May cause impaired alertness or nausea. This medication has physically addictive
properties and withdrawal may follow abrupt discontinuation.
(v). Drug Interactions. Narcotics, sedating medications.
(vi). Recommended Laboratory Monitoring. Renal and hepatic function.
(b). Agents not listed which may be useful in the treatment of CRPS and SMP include propranolol,
nifedipine, calcitonin, bisphosphonates and short-term oral steroids, during the acute phase of the disease. Although
propranolol, nifedipine, oral steroids, and calcitonin are used in practice, at this time there is a lack of well-designed
studies to support their effectiveness compared to placebo. In individual patients, they may be effective. There is
some evidence to support the use of intravenous bisphosphonate drugs, currently licensed for use in malignant bone
disease and Paget's disease, in CRPS patients with abnormal bone scans. Oral use of bisphosphonates has not been
studied in CRPS.
7. Orthotics/prosthetics/equipment. Devices and adaptive equipment may be necessary in order to reduce
impairment and disability, to facilitate medical recovery, to avoid re-aggravation of the injury, and to maintain
maximum medical improvement. Refer to the Chronic Pain Medical Treatment Guidelines for detailed information
on Orthotics/Prosthetics/Equipment.
8. Patient education. Patients should be educated on their specific injury, assessment findings, and plan of
treatment and encouraged to take an active role in establishing functional outcome goals. No treatment plan is
complete without addressing issues of individual and/or group patient education as a means of prolonging the
beneficial effects of rehabilitation, as well as facilitating self-management of symptoms and prevention of secondary
disability. There is good evidence that patient education in self-management of asthma, anticoagulation, and other
diseases improves appropriate use of medications, increases patient satisfaction with care, and reduces unscheduled
physician visits for dealing with complications of treatment.
a. Patient education is an interactive process that provides an environment where the patient not only
acquires knowledge but also gains an understanding of the application of that knowledge. Therefore, patients should
be able to describe and/or will need to be educated on:
i.
The treatment plan.
ii.
Indications for and potential side effects of medications.
iii.
Their home exercise program.
iv.
Expected results of treatment.
v.
Tests to be performed, the reasons for them and their results.
vi.
Activity restrictions and return-to-work status.
vii.
Home management for exacerbations of pain.
viii.
Procedures for seeking care for exacerbations after office hours.
ix.
Home self-maintenance program.
x.
Patient responsibility to communicate with all medical providers and the employer; and
xi.
Patient responsibility to keep appointments.
b. Educational efforts should also extend to family and other support persons, the case manager, the insurer
and the employer as indicated to optimize the understanding of the patient and the outcome. Professional translators
should be provided for non-English speaking patients to assure optimum communication. All education, teaching,
and instruction given to the patient should be documented in the medical record.
c. Effects of education weaken over time; continuing patient education sessions will be required to
maximize the patient’s function. The effectiveness of educational efforts can be enhanced through attention to the
learning style and receptivity of the patient. Written educational materials may reinforce and prolong the impact of
verbal educational efforts. Overall, patient education should emphasize health and wellness, return to work and
return to a productive life.
i.
Time to produce effect: Varies with individual patient
ii.
Frequency: At each visit
9. Personality/psychological/psychiatric/
psychosocial intervention. Psychosocial treatment is generally accepted, well-established therapeutic and diagnostic
procedure with selected use in acute pain problems, but with more widespread use in sub-acute and chronic pain
populations. Psychosocial treatment is recommended as an important component in the total management of a
patient with chronic pain and should be implemented as soon as the problem is identified.
a. Once a diagnosis consistent with the standards of the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM) has been determined, the patient should be evaluated for the potential
need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the
authorized treating physician or by the consulting psychiatrist and/or medical psychologists. Visits for management
of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore,
separate visits for medication management may be necessary, depending upon the patient and medications selected.
b. The screening or diagnostic workup should have clarified and distinguished between preexisting,
aggravated, and or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are
not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a
multi-disciplinary model, or within a structured pain management program.
c. Refer to Chronic Pain guideline for detailed information on whom may perform the service and
timeframe parameters.
10. Restriction of activities. Continuation of normal daily activities is the recommendation for chronic pain
patients since immobility will negatively affect rehabilitation. Prolonged immobility results in a wide range of
deleterious effects, such as a reduction in aerobic capacity and conditioning, loss of muscle strength and flexibility,
increased segmental stiffness, promotion of bone demineralization, impaired disc nutrition, and the facilitation of the
illness role.
a. Patients should be educated to the detrimental effects of immobility versus the efficacious use of rest
periods. Adequate rest allows the patient to comply with active treatment and benefit from the rehabilitation
program. In addition, complete work cessation should be avoided, if possible, since it often further aggravates the
pain presentation and promotes disability. Modified return to work is almost always more efficacious and rarely
contraindicated in the vast majority of injured workers with chronic pain.
11. Return-to-work is one of the major components in chronic pain management. Return to work is a subject
that should be addressed by each workers’ compensation provider at the first meeting with the injured employee, and
be updated at each additional visit. A return to work format should be part of a company’s health plan, knowing that
return to work can decrease anxiety, reduce the possibility of depression, and reconnect the worker with society.
a. Because a prolonged period of time off work will decrease the likelihood of return to work, the first
weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset. In complex cases,
experienced nurse case managers may be required to assist in return to work. Other services, including
psychological evaluation and/or treatment and vocational assistance should be employed.
b.
The following should be considered when attempting to return an injured worker with chronic pain to
work.
i.
Job History Interview. The authorized treating physician should perform a job history interview at the
time of the initial evaluation and before any plan of treatment is established. Documentation should include the
workers’ job demands, stressors, duties of current job, and duties of job at the time of the initial injury. In addition,
cognitive and social issues should be identified and treatment of these issues should be incorporated into the plan of
care.
ii.
Coordination of Care. Management of the case is a significant part of return to work and may be the
responsibility of the authorized treating physician, occupational health nurse, risk manager, or others. Case
management is a method of communication between the primary provider, referral providers, insurer, employer and
employee. Because case management may be coordinated by a variety of professionals, the case manager should be
identified in the medical record.
iii.
Communication is essential between the patient, authorized treating physician, employer and insurer.
Employers should be contacted to verify employment status, job duties and demands, and policies regarding injured
workers. In addition, availability of temporary and permanent restrictions, for what duration, as well as other
placement options should be discussed and documented.
iv.
Establishment of a Return-To-Work Status. Return to work for persons with chronic pain should be
thought of as therapeutic, assuming that work is not likely to aggravate the basic problem or increase the discomfort.
In most cases of chronic pain, the worker may not be currently working or even employed. The goal of return to
work would be to implement a plan of care to return the worker to any level of employment with the current
employer or to return them to any type of new employment.
v.
Establishment of Activity Level Restrictions. A formal job description for the injured/ill employee who
is employed is necessary to identify physical demands at work and assist in the creation of modified duty. A jobsite
evaluation may be utilized to identify tasks such as pushing, pulling, lifting, reaching above shoulder level, grasping,
pinching, sitting, standing, posture, ambulatory distance and terrain, and if applicable, environment for temperature,
air flow, noise and the number of hours that may be worked per day. Work restrictions assigned by the authorized
treating physician may be temporary or permanent. The case manager should continue to seek out modified work
until restrictions become less cumbersome or as the worker’s condition improves or deteriorates.
vi.
Rehabilitation and Return to Work. As part of rehabilitation, every attempt should be made to simulate
work activities so that the authorized treating physician may promote adequate job performance. The use of
ergonomic or adaptive equipment, therapeutic breaks, and interventional modalities at work may be necessary to
maintain employment.
vii.
Vocational Assistance. Formal vocational assistance is a generally accepted intervention and can assist
disabled persons to return to viable employment. Assisting patients to identify vocational goals will facilitate
medical recovery and aid in the maintenance of MMI by increasing motivation towards treatment and alleviating the
patient’s emotional distress. Chronic pain patients will benefit most if vocational assistance is provided during the
interdisciplinary rehabilitation phase of treatment. To assess the patient’s vocational capacity, a vocational
assessment may be utilized to identify rehabilitation program goals, as well as optimize both patient motivation and
utilization of rehabilitation resources.
(a). Employers and employees of small businesses who are diagnosed with chronic pain may not be able
to perform any jobs for which openings exist. Temporary employees may fill those slots while the employee
functionally improves. Some small businesses hire other workers and if the injured employee returns to the job, the
supervisor/owner may have an extra employee. To avoid this, it is suggested that case managers be accessed through
their insurer or third party insurers. Case managers may assist with resolution of these problems, as well as assist in
finding modified job tasks, or find jobs with reduced hours, etc., depending upon company philosophy and
employee needs.
(b). Employers and employees of mid-sized and large businesses are encouraged by the OWCA to
identify modified work within the company that may be available to injured workers with chronic pain who are
returning to work with temporary or permanent restrictions. To assist with temporary or permanent placement of the
injured worker, it is suggested that a program be implemented that allows the case manager to access descriptions of
all jobs within the organization.
12. Therapy — active is based on the philosophy that therapeutic exercise and/or activity are beneficial for
restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.
a. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This
form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile
instruction(s). Active therapy is intended to promote independence and self-reliance in managing the physical pain
as well as to improve the functional status in regard to the specific diagnosis and general conditioning and wellbeing. At times, a provider may help stabilize the patient or guide the movement pattern but the energy required to
complete the task is predominately executed by the patient.
b. Patients should be instructed to continue active therapies at home as an extension of the treatment
process in order to maintain improvement levels. Home exercise can include exercise with or without mechanical
assistance or resistance and functional activities with assistive devices.
c. Since CRPS and SMP patients frequently have additional myofascial pain generators, other active
therapies not listed may be used in treatment. Refer to the Chronic Pain Medical Treatment Guideline for therapies
and timeframe parameters not listed. The following active therapies are listed in alphabetical order:
i.
Activities of Daily Living (ADL) Activities of daily living are instruction, active-assisted training,
and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as selfcare, work re-integration training, homemaking and driving.
(a). Time to produce effect: four to five treatments
(b). Frequency: three to five times per week
(c). Optimum duration: four to six weeks
(d). Maximum duration: six weeks
ii.
Aquatic Therapy is the implementation of active therapeutic procedures (individual or group) in a
swimming or therapeutic pool heated to 88-92 degrees. The water provides a buoyancy force that lessens the amount
of force gravity applies to the body, and the pool should be large enough to allow full extremity range of motion and
full erect posture. The decreased gravity effect allows the patient to have a mechanical advantage increases the
likelihood of successful therapeutic exercise. Multiple limb involvement, weight bearing problems, and vasomotor
abnormalities are frequently treated with water exercise. Indications for individuals who may not tolerate active
land-based or full weight bearing therapeutic procedures or who require augmentation or other therapy. Aquatic
vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.
(a). Time to produce effect: 5 to 10 sessions
(b). Frequency: one to three times per week
(c). Optimum duration: four to six weeks
(d). Maximum duration: Six weeks. Multiple limb involvement may require longer intervention.
iii.
Gait Training. Indications include the need to promote normal gait pattern with assistive devices and/or
to reduce risk of fall or loss of balance. This may include instruction in safety and proper use of assistive devices
and gait instruction on uneven surfaces and steps (with or without railings).
(a). Time to produce effect: one to six sessions
(b). Frequency: one to three times per week
(c). Optimum duration: two weeks. Could be needed intermittently as changes in functional status occur.
(d). Maximum duration: one month.
iv.
Neuromuscular Re-education is the skilled application of exercise with manual, mechanical, or
electrical facilitation to enhance strength, movement patterns, neuromuscular response, proprioception, kinesthetic
sense, coordination, education of movement, balance, and posture. Indications include the need to promote
neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in
patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent
control.
(a). Time to produce effect: six treatments
(b). Frequency: one to three times per week
(c). Optimum duration: four to eight weeks
(d). Maximum Duration: 8 to 12 weeks
v.
Stress Loading is considered a reflex and sensory integration technique involving the application of a
compressive load and a carry load. It is carried out in a consistent, progressive manner and integrated as part of a
home program. Use of this technique may increase symptoms initially, but symptoms generally subside with
program consistency.
(a). Time to produce effect: three weeks
(b). Frequency: two to three times per week.
(c). Optimum duration: Four to six weeks and concurrent with an active daily home exercise program.
(d). Maximum Duration: 6 to 10 weeks
vi.
Therapeutic exercise with or without mechanical assistance or resistance, may include isoinertial,
isotonic, isometric and isokinetic types of exercises. Stress loading exercises are recommended. Indications include
the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength
and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of
muscle recruitment, increased range of motion and are used to promote normal movement patterns. This can also
include, alternative/complementary exercise movement therapy. Therapeutic exercise programs should be tissue
specific to the injury and address general functional deficits as identified in the diagnosis and clinical assessment.
Patients should be instructed in and receive a home exercise program that progresses as their functional status
improves. Upon discharge, the patient would be independent in the performance of the home exercise program and
would have been educated in the importance of continuing such a program. Educational goals would be to maintain
or further improve function and to minimize the risk for aggravation of symptoms in the future.
(a). Time to produce effect: three weeks
(b). Frequency: one to three times per week
(c). Optimum duration: Four to eight weeks and concurrent with an active daily home exercise program.
(d). Maximum Duration: 8 to 12 weeks of therapist oversight. Home exercise should continue
indefinitely.
13. Therapy — passive. Most of the following passive therapies and modalities are generally accepted methods
of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require
energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and
are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft
tissue injuries. They should be used adjunctively with active therapies to help control swelling, pain and
inflammation during the rehabilitation process. They may be used intermittently as a therapist deems appropriate, or
regularly if there are specific goals with objectively measured functional improvements during treatment.
a. Factors such as exacerbation of symptoms, re-injury, interrupted continuity of care, and co-morbidities
may extend durations of care. Having specific goals with objectively measured functional improvement during
treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is
observed, alternative treatment interventions, further diagnostic studies or further consultations should be pursued.
b. Since CRPS and SMP patients frequently have additional myofascial pain generators, other passive
therapies not listed may be used in treatment. Refer to the Chronic Pain Disorder Medical Treatment Guideline’s for
therapies and timeframe parameters not listed. The following passive therapies are listed in alphabetical order:
i.
Continuous Passive Motion (CPM): is rarely indicated in CRPS but may occasionally be warranted if
the patient shows signs of contracture despite active therapy.
(a). Time to produce effect: Four to six treatments
(b). Frequency: Varies, between two to three times per day and one time per week.
(c). Optimum duration: Four treatments
(d). Maximum duration: Six treatments. Provide home unit with improvement.
ii.
Fluidotherapy. Used primarily for desensitization and to facilitate increased active range of motion.
Thermal heat conduction and convection is advantageous for vasodilation, muscle relaxation, and preparation for
stress and activity (exercise).
(a). Time to produce effect: Three treatments
(b). Frequency: Three times per week
(c). Optimum duration: Two months
(d). Maximum duration: Two months as a primary therapy or intermittently as an adjunct therapy to
other procedures.
iii.
Orthotics/Splinting. Static splinting is discouraged. Dynamic splinting may occasionally be useful in
controlling proximal hypertonicity or for other concurrent pain generators.
(a). Time to produce effect: One week
(b). Frequency: varies depending upon application
(c). Optimum duration: One month
(d). Maximum duration: Two months
iv.
Paraffin Bath. Indications include the need to enhance collagen extensibility before stretching, reduce
muscle guarding, and to prepare for functional restoration activities.
(a). Time to produce effect: One to two treatments
(b). Frequency: One to three times per week as an adjunct treatment to other procedures. May use daily
if available at home
(c). Optimum duration: Two weeks
(d). Maximum duration: Three to four weeks. If effective, purchase home unit.
v.
Desensitization is accomplished through sensory integration techniques. Concurrent desensitization
techniques are generally accepted as a treatment for CRPS. Home techniques using soft cloths of various textures,
massage, and vibrators may be beneficial in reducing allodynia and similar sensory abnormalities.
(a). Time to produce effect: Six treatments
(b). Frequency: Three times per week and concurrent with home exercise program
(c). Optimum duration: Three weeks with reinforcement of home program
(d). Maximum duration: One month.
vi.
Superficial Heat Therapy. Superficial heat is a thermal agent applied to raise the body tissue
temperature. It is indicated before exercise to elevate the pain threshold, alleviate muscle spasm, and promote
increased movement. Heat packs can be used at home as an extension of therapy in the clinic setting.
(a). Time to produce effect: Immediate
(b). Frequency: One to three times per week
(c). Optimum duration: Two weeks as primary or intermittently as an adjunct to other therapeutic
procedures.
(d). Maximum duration: Two weeks. Home use as a primary modality may continue at the providers’
discretion.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1723 (June 2011).
§2133. Therapeutic ProceduresOperative
A. When considering operative intervention in chronic pain management, the treating physician must carefully
consider the inherent risk and benefit of the procedure. All operative intervention should be based on a positive
correlation with clinical findings, the clinical course, and diagnostic tests. A comprehensive assessment of these
factors should have led to a specific diagnosis with positive identification of the pathologic conditions(s).
B. Surgical procedures are seldom meant to be curative and would be employed in conjunction with other
treatment modalities for maximum functional benefit. Functional benefit should be objectively measured and
includes the following:
1.
Return to work or maintaining work status.
2.
Fewer restrictions at work or performing activities of daily living (ADL).
3.
Decrease in usage of medications.
4.
Measurable functional gains, such as increased range of motion or documented increase in strength.
C. Education of the patient should include the proposed goals of the surgery, expected gains, risks or
complications, and alternative treatment.
1. Intrathecal drug delivery. This mode of therapy delivers small doses of medications directly into the
cerebrospinal fluid. Refer to the Chronic Pain Medical Treatment Guideline’s for detailed information and
recommendations for its use in CRPS patients with chronic pain.
2. Neurostimulation is the delivery of low-voltage electrical stimulation to the spinal cord or peripheral nerves
to inhibit or block the sensation of pain. Refer to the Chronic Pain Medical Treatment Guideline’s for detailed
information and recommendations for its use in CRPS patients with chronic pain.
3.
Sympathectomy
a. Description. Destruction of part of the sympathetic nervous system, which is not generally accepted or
widely used. Long-term success with this pain relief treatment is poor. This procedure requires prior authorization.
b. Indications. Single extremity CRPS-I or SMP; distal pain only (should not be done if the proximal
extremity is involved). Local anesthetic Stellate Ganglion Block or Lumbar Sympathetic Block consistently gives 90
to 100 percent relief each time a technically good block is performed (with measured rise in temperature). The
procedure may be considered for individuals who have limited duration of relief from blocks. Permanent
neurological complications are common.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1733 (June 2011).
§2135. Maintenance Management
A. Successful management of chronic pain conditions results in fewer relapses requiring intense medical care.
Failure to address long-term management as part of the overall treatment program may lead to higher costs and
greater dependence on the health care system. Management of CRPS and SMP continues after the patient has met
the definition of maximum medical improvement (MMI). MMI is declared when a patient’s condition has plateaued
and the authorized treating physician believes no further medical intervention is likely to result in improved
function. When the patient has reached MMI, a physician must describe in detail the maintenance treatment.
B. Maintenance care in CRPS and SMP requires a close working relationship between the carrier, the providers,
and the patient. Providers and patients have an obligation to design a cost effective, medically appropriate program
that is predictable and allows the carrier to set aside appropriate reserves. Carriers and adjusters have an obligation
to assure that medical providers can plan medically appropriate programs. A designated primary physician for
maintenance team management is recommended.
C. Maintenance Care will be based on principles of patient self-management. When developing a maintenance
plan of care, the patient, physician and insurer should attempt to meet the following goals:
1. Maximal independence will be achieved through the use of home exercise programs or exercise programs
requiring special facilities (e.g., pool, health club) and educational programs;
2.
Modalities will emphasize self management and self-applied treatment;
3. Management of pain or injury exacerbations will emphasize initiation of active therapy techniques and may
occasionally require anesthetic injection blocks.
4. Dependence on treatment provided by practitioners other than the authorized treating physician will be
minimized;
5.
Periodic reassessment of the patient’s condition will occur as appropriate.
6. Patients will understand that failure to comply with the elements of the self-management program or
therapeutic plan of care may affect consideration of other interventions.
D. Specific Maintenance Interventions and Parameters
1. Home exercise programs and exercise equipment. Most patients have the ability to participate in a home
exercise program after completion of a supervised exercise rehabilitation program. Programs should incorporate an
exercise prescription including the continuation of an age-adjusted and diagnosis-specific program for aerobic
conditioning, flexibility, stabilization, and strength. Some patients may benefit from the purchase or rental of
equipment to maintain a home exercise program. Determination for the need of home equipment should be based on
medical necessity to maintain MMI, compliance with an independent exercise program, and reasonable cost. Before
the purchase or long-term rental of equipment, the patient should be able to demonstrate the proper use and
effectiveness of the equipment. Effectiveness of equipment should be evaluated on its ability to improve or maintain
functional areas related to activities of daily living or work activity. Occasionally, compliance evaluations may be
made through a 4-week membership at a facility offering similar equipment. Home exercise programs are most
effective when done three to five times a week.
2. Exercise programs requiring special facilities. Some patients may have higher compliance with an
independent exercise program at a health club versus participation in a home program. All exercise programs
completed through a health club facility should focus on the same parameters of an age-adjusted and diagnosisspecific program for aerobic conditioning, flexibility, stabilization, and strength. Selection of health club facilities
should be limited to those able to track attendance and utilization, and provide records available for physician and
insurer review. Prior to purchasing a membership, a therapist and or exercise specialist who has treated the patient
may visit the facility with the patient to assure proper use of the equipment.
a.
Frequency: two to three times per week.
b.
Optimal Duration: one to three months.
c. Maximum Maintenance duration: Three months. Continuation beyond three months should be based on
functional benefit and patient compliance. Health club membership should not extend beyond three months if
attendance drops below two times per week on a regular basis.
3. Patient education management. Educational classes, sessions, or programs may be necessary to reinforce
self-management techniques. This may be performed as formal or informal programs, either group or individual.
a.
Maintenance duration: Two to six educational sessions during one 12-month period.
4. Psychological management. An ideal maintenance program will emphasize management options
implemented in the following order: individual self-management (pain control, relaxation and stress management,
etc.), group counseling, individual counseling by a psychologist or psychiatrist and in-patient treatment. Aggravation
of the injury may require more intense psychological treatment to restore the patient to baseline. In those cases, use
treatments and timeframe parameters listed in the Biofeedback and Psychological Evaluation or Intervention
sections.
a.
Maintenance duration: 6 to 10 visits during one 12-month period.
5. Non-narcotic medication management. In some cases, self-management of pain and injury exacerbations
can be handled with medications, such as those listed in Medication Section. Physicians must follow patients who
are on any chronic medication or prescription regimen for efficacy and side effects. Laboratory or other testing may
be appropriate to monitor medication effects on organ function.
a. Maintenance duration: Usually, four medication reviews within a 12-month period. Frequency depends
on the medications prescribed. Laboratory and other monitoring as appropriate.
6. Narcotic medication management. As compared with other pain syndromes, there may be a role for chronic
augmentation of the maintenance program with narcotic medications. In selected cases, scheduled medications may
prove to be the most cost effective means of insuring the highest function and quality of life; however, inappropriate
selection of these patients may result in a high degree of iatrogenic illness. A patient should have met the criteria in
opioids section of these guidelines before beginning maintenance narcotics. Laboratory or other testing may be
appropriate to monitor medication effects on organ function. The following management is suggested for
maintenance narcotics:
a. The medications should be clearly linked to improvement of function, not just pain control. All follow up
visits should document the patient’s ability to perform routine functions satisfactorily. Examples include the abilities
to: perform work tasks, drive safely, pay bills or perform basic math operations, remain alert for 10 hours, or
participate in normal family and social activities. If the patient is not maintaining reasonable levels of activity the
patient should usually be tapered from the narcotic and tried on a different long-acting opioid.
b. A low dose narcotic medication regimen should be defined, which may minimally increase or decrease
over time. Dosages will need to be adjusted based on side effects of the medication and objective function of the
patient. A patient may frequently be maintained on additional non-narcotic medications to control side effects, treat
mood disorders, or control neuropathic pain; however, only one long-acting narcotic and one short-acting narcotic
for rescue use should be prescribed in most cases.
c. All patients on chronic narcotic medication dosages need to sign an appropriate narcotic contract with
their physician for prescribing the narcotics.
d. The patient must understand that continuation of the medication is contingent on their cooperation with
the maintenance program. Use of non-prescribed drugs may result in tapering of the medication. The clinician may
order random drug testing when deemed appropriate to monitor medication compliance.
e.
Patients on chronic narcotic medication dosages must receive them through one prescribing physician.
i.
Maintenance duration: Up to 12 visits within a 12-month period to review the narcotic plan.
Laboratory and other monitoring as appropriate.
7. Therapy management. Some treatment may be helpful on a continued basis during maintenance care if the
therapy maintains objective function and decreases medication use. Aggravation of the injury may require intensive
treatment to get the patient back to baseline. In those cases, treatments and timeframe parameters listed in Section H,
13 and 14, Active and Passive Therapy.
a.
period.
8.
Active Therapy, Acupuncture, and Manipulation maintenance duration:
10 visits in a 12-month
Injection therapy
a. Sympathetic Blocks. These injections are considered appropriate if they maintain or increase function for
a minimum of four to eight weeks. Maintenance blocks are usually combined with and enhanced by the appropriate
neuropharmacological medication(s) and other care. It is anticipated that the frequency of the maintenance blocks
may increase in the cold winter months or with stress.
i.
Maintenance duration. Not to exceed six to eight blocks in a 12-month period for a single extremity
and to be separated by no less than four-week intervals. Increased frequency may need to be considered for multiple
extremity involvement or for acute recurrences of pain and symptoms. For treatment of acute exacerbations,
consider 2 to 6 blocks with a short time interval between blocks.
b. Trigger Point Injections. These injections may occasionally be necessary to maintain function in those
with myofascial problems.
i.
Maintenance duration. Not more than four injections per session not to exceed three to six sessions per
12-month period.
9. Purchase or rental of durable medical equipment. It is recognized that some patients may require ongoing
use of self-directed modalities for the purpose of maintaining function and or analgesic effect. Purchase or rental of
modality based equipment should be done only if the assessment by the physician and or therapist has determined
the effectiveness, compliance, and improved or maintained function by its application. It is generally felt that large
expense purchases such as spas, whirlpools, and special mattresses are not necessary to maintain function beyond
the areas listed above.
a.
Maintenance duration: Not to exceed three months for rental equipment. Purchase if effective.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.
HISTORICAL NOTE: Promulgated by the Louisiana Workforce Commission, Office of Workers Compensation
Administration, LR 37:1734 (June 2011).